Professional Documents
Culture Documents
of Intrauterine Devices
BRETT ANDREW JOHNSON, M.D., Methodist Charlton Medical Center, Dallas, Texas
The intrauterine device (IUD) is an effective contraceptive for many women. The copper-releasing IUD can be used for 10 years before replacement and is a good choice for women who cannot,
or choose not to, use hormone-releasing contraceptives. However, some women experience an
increase in menstrual blood loss and dysmenorrhea. The progestin-releasing IUD can be used for
five years. It may reduce menorrhagia and dysmenorrhea, although some women have increased
spotting and bleeding during the first months after insertion. The ideal candidates for IUD use are
parous women in stable, monogamous relationships. Pregnancy, unexplained vaginal bleeding,
and a lifestyle placing the woman at risk for sexually transmitted diseases are contraindications to
IUD use. Insertion of the IUD can take place at any time during the menstrual cycle provided the
woman is not pregnant. Before insertion, a bimanual examination and a sounding of the uterus
are necessary to determine the uterus position and the depth of the uterine cavity. The IUD is
inserted into the uterus according to individual protocols, with the threads cut at a length to allow
the patient to check the devices position. Expulsion may occur with both types of IUDs. (Am Fam
Physician 2005;71:95-102. Copyright 2005 American Academy of Family Physicians.)
See page 27 for levels-ofevidence definitions.
Horizontal arms
Flange
Insertion tube
Vertical arm
Solid rod
Threads
January 1, 2005
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The Author
BRETT ANDREW JOHNSON, M.D., is program director of the Methodist Health
System of Dallas Family Practice Residency at Methodist Charlton Medical
Center, Dallas. He also is an associate professor of family and community medicine at the University of Texas Southwestern Medical School, Dallas. He received
his medical degree from the State University of New York School of Medicine,
Buffalo, and completed a residency in family medicine at Hamot Family Practice
Residency Program, Erie, Pa.
Address correspondence to Brett A. Johnson, M.D., Methodist Charlton Medical
Center, 3500 W. Wheatland Rd., Dallas, TX 75237. Reprints are not available
from the author.
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Arms
Mirena IUD
Scale
Flange
Insertion tube
with plunger inside
Slider
Mark
Handle
Thread cleft
Threads
IUD. A World Health Organization scientific working group concluded that women
who have been pregnant after an occurrence
of PID and are not currently at risk for infection can be candidates for IUDs.1
The hormone-releasing IUD may benefit
women with anemia, menorrhagia, or dysmenorrhea.8 While there is a greater risk
for spotting or irregular bleeding during
the first three months after insertion of this
device, the risk decreases significantly at 12
months post-insertion.9
Both IUDs are classified as pregnancy category X. Contraindications are summarized
in Table 1.4,5,7,10,11
Precautions
IUDs may be inserted anytime during the
menstrual cycle. Documentation of a negative pregnancy test is prudent. Insertion may
be performed during menstruation to proVolume 71, Number 1
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IUD Insertion
TABLE 1
TABLE 2
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be pulled back on the insertion rod approximately 2 cm so that the arms can spread to
the T position (Figure 4). The tube should
be advanced slowly to ensure a correct positioning of the IUD (Figure 5). The physician should remove the insertion rod by
holding the insertion tube in place (Figure
6) and then remove the insertion tube and
the tenaculum. Finally, the threads emerging from the cervical os should be cut to a
length of 3 cm. The length of the threads in
the vagina should be noted in the patients
record for further reference.
HORMONE-RELEASING IUD
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IUD Insertion
Retract
Stationary
Slider
Stationary
Stationary
Retract
Sound
measure
1.5 to 2 cm
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January 1, 2005
IUD Insertion
Mark
Hold inserter in
place and pull
down slider.
TABLE 3
Cramping
Displaced threads
Ectopic pregnancy
Embedment or fragmentation of IUD
Expulsion
Infertility
Pelvic infections
Septicemia during pregnancy
Tubo-ovarian damage
Uterine or cervical perforation
Vaginal bleeding, with or without anemia
Vasovagal reaction (on insertion)
IUD = intrauterine device.
Information from references 4, 5, 7, 11, and 12.
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IUD Insertion
REFERENCES
1. IUDsan update. Popul Rep B 1995;(6):1-35.
2. Spinatto JA 2d. Mechanism of action of intrauterine
contraceptive devices and its relation to informed consent. Am J Obstet Gynecol 1997;176:503-6.
3. Stanford JB, Mikolajczyk RT. Mechanisms of action of
intrauterine devices: update and estimation of postfertilization effects. Am J Obstet Gynecol 2002;187:1699708.
4. Mirena [package insert]. Montville, N.J.: Berlex Laboratories, 2003.
9. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five
years of use: a randomized comparative trial. Contraception 1994;49:56-72.
10. Physicians Desk Reference. 58th ed. Montvale, N.J.:
Thomson PDR, 2004.
11.Canavan TP. Appropriate use of the intrauterine device.
Am Fam Physician 1998;58:2077-84,2087-8.
12. American College of Obstetricians and Gynecologists.
The intrauterine device. ACOG technical bulletin no.
164. Washington, D.C.: ACOG, 1992.
13. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev 2001;(1):CD001327. Update in: Cochrane
Database Syst Rev 2001;(2):CD001327.
6. Doll H, Vessey M, Painter R. Return of fertility in nulliparous women after discontinuation of the intrauterine
device: comparison with women discontinuing other
methods of contraception. BJOG 2001;108:304-14.
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January 1, 2005